Perspectives From Students and Faculty on How Women Achieve Leadership Roles in Academic Medicine: An Exploratory Qualitative Study.

INTRODUCTION: The glass ceiling in academic medicine has resulted in lower pay and fewer career advancement opportunities for women. Creating change relies on preparing early-career women for positions of leadership, but most leadership programs focus on faculty, not trainees. The present exploratory qualitative study investigates how to prepare women medical students to be leaders in academic medicine. METHODS: Focus groups with medical students and faculty who identify as women were conducted at an academic medical center in the West. A total of 25 individuals (10 students and 15 faculty) participated. Recordings of focus groups were transcribed and coded using thematic analysis until saturation of themes was achieved. FINDINGS: Codes were organized into three themes: obstacles, support systems, and self-presentation. Obstacles identified included the subthemes microaggressions, macroaggressions, a lack of female role models in leadership, and personal characteristics such as the ability to self-promote and remain resilient. Support systems included sponsorship, allyship, mentorship, networking, and gender-specific role modeling subthemes. Self-presentation involved learning behaviors for demonstrating leadership and exuding confidence, being strategic about career moves, resiliency, and navigating social norms. CONCLUSIONS: The key themes of obstacles, support systems, and self-presentation are targets for systemic and individualistic improvement in leadership development.

Cannulation strategies for extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal life support (ECLS) in which the function of the heart and/or lungs is partially or completely replaced by a portable system that provides prolonged support to critically ill patients with respiratory or cardiac failure. There are two major variants of ECMO: veno-venous (VV) ECMO and veno-arterial (VA) ECMO. VV ECMO replaces the function of the lung in which it uses a cannula to remove venous blood and oxygenates it using the extracorporeal system, and returns the blood to the right atrium to be pumped to the body. VA ECMO is slightly different in that it replaces the function of the heart and lungs by returning oxygenated blood to the aorta. As a therapy for respiratory failure, ECMO minimizes hypoxia, diminishes lung stress and strain, and allows lung protective mechanical ventilation. As a support for acute and terminal heart failure, ECMO reduces preload, increases aortic flow, and allows for end-organ perfusion. Due to its physiological support and advantages, it is used for a variety of chronic and acute support purposes such as bridge therapy for heart/lung transplant, durable ventricular assist devices, and intermediate-term mechanical support postoperatively. Our review gives a broad overview of the two main types of ECMO strategies and their clinical indications, cannulation strategies, unique clinical utility, and their limitations.

Practice patterns of female cardiothoracic surgeons older than age 58 years: Are we making progress?

OBJECTIVE: Women remain a small minority of cardiothoracic surgeons, and within adult cardiac surgery, the gender gap widens. This study examines the career pathway and trajectory of female adult cardiac surgeons. METHODS: Female cardiothoracic surgeons were identified from the American Board of Thoracic Surgery diplomates over 58 years. Publicly available information was obtained to determine years in practice, practice type, academic and leadership title(s), and location of practice. RESULTS: The average number of years in practice for female adult cardiac surgeons was 13.1. Those categorized as adult cardiac surgeons composed 25.4% (n = 90) of all female cardiothoracic diplomates and 134 (37.9%) were categorized as other subspecialty practice. Of the adult cardiac surgeons, 33.3% (n = 30) practiced privately and the remainder in academic practice. Academic titles were held by 47.8% (43 out of 90) and 30% (27 out of 90) held a position of leadership. Of those in academic practice, 25% (11 out of 42) are titled professor, whereas 43% (18 out of 42) are assistant professors. Most commonly, those in positions of leadership held the title "director," which reflects 37% (10 out of 27) of individuals. Practice locations were distributed throughout the United States, with the highest number in the northeast (26.7%). CONCLUSIONS: Only a small portion of female cardiothoracic surgeons pursue a career in adult cardiac surgery compared to their male counterparts. From 1999 to 2009, 1300 individuals were board certified cardiothoracic surgeons, of whom only 103 (7.9%) were female. Of these, the majority of female cardiothoracic surgeons entered academic practice. Although the overall number of practicing female adult cardiac surgeons has increased with a growth rate of 10.7%, this number remains extremely low. A discrepancy remains between gender representation of academic titles and leadership positions. Although the field has increased female representation over the past few decades, work remains to ensure all potential talent is encouraged and supported.

Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling.

The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.

Acute myeloid leukemia causing acute thrombosis of the coronary arteries: a case report.

BACKGROUND: This case report demonstrates acute myeloid leukemia causing acute thrombosis of coronary arteries with anterolateral ST elevation myocardial infarction and ventricular tachycardia in an otherwise healthy woman. Few case reports have been documented on patients with concomitant conditions of acute myeloid leukemia and acute myocardial infarction, and it is important to note that prognosis for patients with both is worse than that of either condition. While both conditions together are rare, other non-atherosclerotic causes of acute coronary syndromes are likewise important considerations in the context of myocardial ischemia. CASE PRESENTATION: A 59-year-old Caucasian woman with no notable past medical history presented to her primary care provider with 2 weeks of severe fatigue, anorexia, and malaise, associated with chills, night sweats, and myalgias. Peripheral blood smear identified 92% blasts consistent with acute myeloid leukemia and computed tomography identified a right segmental pulmonary embolism and thrombotic infarcts in the spleen, bilateral kidneys, right lung, and liver. Laboratory testing also demonstrated disseminated intravascular coagulopathy. She was admitted to the intensive care unit for treatment and subsequently developed ventricular tachycardia, anterolateral ST segment elevation, acute dysarthria, and nonreactive pupils. Pulseless electrical activity developed with unsuccessful resuscitative measures. The patient died secondary to presumed cerebrovascular and coronary thromboses causing stroke and anterolateral infarct complicated by ventricular tachycardia and pulseless electrical activity. CONCLUSION: This case is notable as a case of acute myeloid leukemia causing acute thrombosis of coronary arteries with anterolateral ST elevation myocardial infarction, ventricular tachycardia, and pulseless electrical activity. Prognosis of concomitant acute myeloid leukemia and acute myocardial infarction is poor. Management is challenging due to thrombocytopenia, platelet dysfunction, and systemic coagulopathy, and administration of thrombolytic agents can be fatal. This is an extreme presentation of a case of acute myocardial infarction with disseminated intravascular coagulopathy causing acute coronary thrombosis and sudden death with dramatic electrocardiogram and telemetry findings recorded with rapid progression from normal sinus rhythm to acute myocardial infarction to terminal rhythm.

The continued inappropriate use and overuse of combination topical clotrimazole-betamethasone.

OBJECTIVE: Combination topical clotrimazole/ betamethasone dipropionate (C-BM) contains a high-potency topical corticosteroid and is not infrequently prescribed for inappropriate patient groups and body sites. Use of C-BM can lead to inadequate clearance or exacerbation of fungal infections as well as cutaneous atrophy, striae, and other skin maladies. METHODS: We performed a retrospective chart review of 1,978 clinical visits where C-BM was prescribed within the University of Utah Health system between 2014 and 2018 to better understand current prescribing patterns. RESULTS: 1,974 prescriptions were written for C-BM. 91.6% of patients were at least the recommended age of 17 years. C-BM was most commonly prescribed for rashes of an inflammatory (42.2%) or fungal nature (38.1%). Clotrimazole/betamethasone dipropionate was prescribed for sensitive areas (face, axillae, groin or diaper region) in 48.9% of patients. Family medicine clinicians prescribed 58.3% of C-BM prescriptions, whereas dermatology clinicians accounted for 3.4%. CONCLUSION: We strongly recommend clinicians use alternative treatments for rashes or refer to dermatologists.

Gender-based Barriers to the Advancement of Women in Academic Emergency Medicine: A Multi-Institutional Survey Study.

INTRODUCTION: Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups. METHODS: An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions. RESULTS: The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents' response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P <0.001). Obstacles reported included a lack of confidence during work-related negotiations and insufficient research experience. Notably, 68.4% (65/95) of respondents experienced gender discrimination and 9.5% (9/95) reported at least one encounter of sexual assault by a colleague or supervisor during their career. CONCLUSION: Targeted interventions to promote female leadership in academic emergency medicine include coaching on negotiation skills, improved resources and mentorship to support research, and enforcement of safe work environments. Female emergency physician resiliency is high and not a barrier to career advancement.

Constrictive pericarditis in the setting of repeated chest trauma in a mixed martial arts fighter.

BACKGROUND: Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium. This case demonstrates that mixed martial arts (MMA) is a previously unrecognized risk factor for CP, diagnosis of which is supported by cardiac imaging, right and left heart catheterization, and histological findings of dense fibrous tissue without chronic inflammation. CASE PRESENTATION: A 47-year-old Caucasian male former mixed martial arts (MMA) fighter from the Western United States presented to liver clinic for elevated liver injury tests (LIT) and a 35-pound weight loss with associated diarrhea, lower extremity edema, dyspnea on exertion, and worsening fatigue over a period of 6 months. Past medical history includes concussion, right bundle branch block, migraine headache, hypertension, chronic pain related to musculoskeletal injuries and fractures secondary to MMA competition. Involvement in MMA was extensive with an 8-year history of professional MMA competition and 13-year history of MMA fighting with recurrent trauma to the chest wall. The patient also reported a 20-year history of performance enhancing drugs including testosterone. Physical exam was notable for elevated jugular venous pressure, hepatomegaly, and trace peripheral edema. An extensive workup was performed including laboratory studies, abdominal computerized tomography, liver biopsy, echocardiogram, and cardiac magnetic resonance imaging. Finally, right and left heart catheterization-the gold standard-confirmed discordance of the right ventricle-left ventricle, consistent with constrictive physiology. Pericardiectomy was performed with histologic evidence of chronic pericarditis. The patient's hospital course was uncomplicated and he returned to NYHA functional class I. CONCLUSIONS: CP can be a sequela of recurrent pericarditis or hemorrhagic effusions and may have a delayed presentation. In cases of recurrent trauma, CP may be managed with pericardiectomy with apparent good outcome. Further studies are warranted to analyze the occurrence of CP in MMA so as to better define the risk in such adults.

The Impact of COVID-19 on Medical Education.

In the wake of the novel coronavirus (COVID-19) pandemic, it is abundantly clear to all the necessity of studying the pathology and widespread health consequences associated with the virus. However, what is much less clear is the impact of COVID-19 on medical education. Already, faculty and medical students are grappling with the changes that have been made and attempting to consolidate these with their plan of career development. Changes that may seem relatively minor in comparison to the global pandemic have the potential to be drastic turning points in the career progression of many. As not much is known regarding the long-lasting impact of COVID-19 on medical education, it is therefore also necessary to record and study the full impact of the changes being made. The path to entering a successful residency has been predictable for the last few years - do well on Step 1, give conference presentations, go the extra mile in clerkships and shadowing opportunities, and have meaningful non-academic extracurricular activities - all of which designed to best demonstrate a student's knowledge, persistence, collaborative spirit, and dedication to medicine. This trajectory has been changed with COVID-19 disrupting routines in hospitals, medical schools and beyond. The replacement of in-person classes with online equivalents is an obvious necessity at this time but creates a loss of collaborative experiences that has the potential to be a significant detriment to education. Likewise, the cancellation of clerkships, which are necessary for both skill acquisition as well as for relationship building, is a serious issue which students and medical schools must now resolve. Many medical students have also lost the opportunity for personal development through conference presentations. These presentations play a large role in distinguishing applicants during the residency application process, and therefore these lost opportunities have the potential to be a serious detriment to medical students' career trajectory. While implementing technology to help resolve these issues is a unique way to help students to develop these skills, it is now necessary for medical students to demonstrate the same set of skills which they would have previously in a completely new and innovative manner. Persistence and adaptability during this time of challenge are attributes that medical students can demonstrate more readily. While every student has a personal story of how COVID-19 has impacted their education, there is no question that the impacts of COVID-19 will be felt on an extensive level. The panic in the community is palpable, and many are confused by how to proceed in the wake of COVID-19. This is no different for medical students and faculty and the questions that arise regarding medical education and their future careers.

Atypical chemokine receptor ACKR2-V41A has decreased CCL2 binding, scavenging, and activation, supporting sustained inflammation and increased Alzheimer's disease risk.

A recent genome-wide association study (GWAS) of 59 cerebrospinal fluid (CSF) proteins with a connection to Alzheimer's disease (AD) demonstrated an association between increased levels of chemokine ligand 2 (CCL2) with an atypical chemokine receptor chemokine-binding protein 2 variant V41A (ACKR2-V41A; rs2228467). High levels of CCL2 are associated with increased risk of AD development as well as other inflammatory diseases. In this study we characterized the biological function of the ACKR2-V41A receptor compared to the wild type allele by measuring its ligand binding affinity, CCL2 scavenging efficiency, and cell activation sensitivity. We transfected Chinese hamster ovary cells with plasmids carrying wild type ACKR2 (ACKR2-WT) or the mutant ACKR2-V41A receptor. Binding affinity assays showed that ACKR2-V41A has a lower binding affinity for CCL2 and CCL4 than ACKR2-WT. CCL2 scavenging results aligned with binding affinity assays, with ACKR2-V41A cells scavenging CCL2 with a lower efficiency than ACKR2-WT. Cell activation assays also showed that ACKR2-V41A cells had significantly lower receptor upregulation (ß-Arrestin-dependent signaling pathway) upon stimulation compared to ACKR2-WT cells. These findings provide molecular and biological mechanistic insights into the GWAS association of ACKR2-V41A with increased levels of CCL2 in CSF and possibly other chemokine ligands. Increased CCL2 levels are associated with accelerated cognitive decline and increased risk of AD. Understanding how this atypical chemokine receptor allele increases serum markers of inflammation could lead to novel therapeutic solutions for AD.

Common DNA Variants Accurately Rank an Individual of Extreme Height.

Polygenic scores (or genetic risk scores) quantify the aggregate of small effects from many common genetic loci that have been associated with a trait through genome-wide association. Polygenic scores were first used successfully in schizophrenia and have since been applied to multiple phenotypes including multiple sclerosis, rheumatoid arthritis, and height. Because human height is an easily-measured and complex polygenic trait, polygenic height scores provide exciting insights into the predictability of aggregate common variant effect on the phenotype. Shawn Bradley is an extremely tall former professional basketball player from Brigham Young University and the National Basketball Association (NBA), measuring 2.29 meters (7'6″, 99.99999th percentile for height) tall, with no known medical conditions. Here, we present a case where a rare combination of common SNPs in one individual results in an extremely high polygenic height score that is correlated with an extreme phenotype. While polygenic scores are not clinically significant in the average case, our findings suggest that for extreme phenotypes, polygenic scores may be more successful for the prediction of individuals.